Provider Demographics
NPI:1104662808
Name:WILHAM, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WILHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860912 MINNEAPOLIS MN 55486-0912 PHONE: 50728
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-5181
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN35073207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program